eviCore Radiation Therapy 2019 Guidelines

1 CLINICAL Guidelines . Radiation Therapy Version Effective March 1, 2019. Clinical Guidelines for medical necessity review of Radiation Therapy services. 2019 eviCore healthcare. All rights reserved. Radiation Therapy Criteria _____. Please note the following: CPT Copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. _____. 2019 eviCore healthcare. All Rights Reserved. Page 2 of 272. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 Radiation Therapy Criteria _____. Please note the following: All information provided by the NCCN is Referenced with permission from the NCCN.

2 Clinical Practice Guidelines in Oncology (NCCN Guidelines ) 2017/2018 National Comprehensive Cancer Network. The NCCN Guidelines and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines , go online to . _____. 2019 eviCore healthcare. All Rights Reserved. Page 3 of 272. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 Radiation Therapy Criteria _____. Dear Provider, This document provides detailed descriptions of eviCore 's basic criteria (also known as clinical Guidelines ) for Radiation Therapy arranged by diagnosis.

3 They have been carefully researched and are continually updated in order to be consistent with the most current evidence-based Guidelines and recommendations for the provision of Radiation Therapy from national medical societies and evidence-based medicine research centers. In addition, the criteria are supplemented by information published in peer-reviewed literature. Our health plan clients review the development and application of these criteria. Every eviCore health plan client develops a unique list of CPT codes or diagnoses that are part of their Radiation Therapy utilization management programs. Health Plan medical policy supersedes the eviCore criteria when there is conflict with the eviCore criteria and the health plan medical policy.

4 If you are unsure of whether or not a specific health plan has made modifications to these basic criteria in their medical policy for Radiation Therapy please contact the plan or access the plan's website for additional information. While eviCore encourages participation in clinical trials when consistent with each health plan's policies, we want to clarify our position on the use of such standard arms outside of the research setting. The use of a control arm or standard arm in a Phase III. clinical trial does not necessarily mean that other standard treatment techniques are not equally effective. Examples of multiple standard arms can easily be found in the treatment of prostate cancer where Intensity-Modulated Radiation Therapy (IMRT), 3- Dimensional (3-D), low dose implant or High Dose Rate (HDR) can be equally effective or breast cancer where standard whole breast fractionation or hypo-fractionation can be used.

5 Indeed, national criteria such as National Comprehensive Cancer Network (NCCN) and American College of Radiology (ACR) Appropriateness Criteria often suggest more than one Radiation technique. It is eviCore 's process to apply evidence-based criteria to the particular clinical characteristics in evaluating a case, and to certify the most appropriate regimen/modality. This regimen/modality may match one that is used as a standard arm in a federally funded clinical trial, or it may be one that is considered an alternate standard . The alternate standard will be one supported by nationally published Guidelines such as the NCCN, ACR Appropriateness Guidelines , or American Society _____.

6 2019 eviCore healthcare. All Rights Reserved. Page 4 of 272. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 Radiation Therapy Criteria _____. for Radiation Oncology (ASTRO) Evidence-Based Guidelines , or supported by other acceptable peer-reviewed publications. As such, eviCore will not automatically certify a case based solely on the fact that it matches the standard (control) arm of a clinical trial. This concept applies also to regimens/modalities listed by the NCCN or ACR as acceptable treatments for specific disease sites. Rather, we commit to working with the providing Radiation Oncologist to certify the most appropriate regimen/modality for a particular case.

7 eviCore healthcare works hard to make your clinical review experience a pleasant one. For that reason, we have peer reviewers available to assist you should you have specific questions about a procedure. For your convenience, eviCore 's Customer Service support is available from 7 to 7. Our toll free number is (800) 918-8924. Gregg P. Allen, FAAFP. EVP and Chief Medical Officer _____. 2019 eviCore healthcare. All Rights Reserved. Page 5 of 272. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 Radiation Therapy Criteria _____. Table of Contents Brachytherapy of the Coronary Arteries .. 7. Hyperthermia .. 16. Image-Guided Radiation Therapy (IGRT).

8 19. Neutron Beam Therapy .. 23. Proton Beam Therapy .. 25. Radiation Therapy for Anal Canal 68. Radiation Therapy for Bladder Cancer .. 71. Radiation Therapy for Bone Metastases .. 75. Radiation Therapy for Brain Metastases .. 80. Radiation Therapy for Breast Cancer .. 88. Radiation Therapy for Cervical Cancer .. 98. Radiation Therapy for Endometrial Cancer .. 105. Radiation Therapy for Esophageal Cancer .. 112. Radiation Therapy for Gastric Cancer .. 117. Radiation Therapy for Head and Neck Cancer .. 120. Radiation Therapy for Hepatobiliary Cancer .. 124. Radiation Therapy for Hodgkin's Lymphoma .. 130. Radiation Therapy for Kidney and Adrenal Cancer.

9 134. Radiation Therapy for Lung Cancer .. 136. Radiation Therapy for Multiple Myeloma and Solitary Plasmacytomas .. 149. Radiation Therapy for Non-Hodgkin's Lymphoma .. 152. Radiation Therapy for Non-malignant 158. Radiation Therapy for 185. Radiation Therapy for Other Cancers .. 191. Radiation Therapy for Pancreatic Cancer .. 192. Radiation Therapy for Primary Craniospinal Tumors and Neurologic Conditions .. 198. Radiation Therapy for Prostate Cancer .. 206. Radiation Therapy for Rectal Cancer .. 213. Radiation Therapy for Skin Cancer .. 216. Radiation Therapy for Soft Tissue Sarcomas .. 224. Radiation Therapy for Testicular Cancer .. 231. Radiation Therapy for Thymoma and Thymic Cancer.

10 234. Radiation Therapy for Urethral Cancer and Upper Genitourinary Tract Tumors 238. Radiation Treatment with Azedra (iobenguane I-131) .. 240. Radiation Treatment with Lutathera (Lutetium; Lu 177 dotatate) .. 243. Radioimmunotherapy with Zevalin .. 248. Selective Internal Radiation Therapy (SIRT) .. 261. Revision History .. 268. _____. 2019 eviCore healthcare. All Rights Reserved. Page 6 of 272. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 Radiation Therapy Criteria Brachytherapy of the Coronary Arteries POLICY. I. Coronary artery brachytherapy A. Is medically necessary when used as an adjunct to percutaneous coronary intervention (PCI) for treatment of in-stent restenosis in a native coronary artery bare-metal stent or saphenous vein graft (SVG).